Medical Review

Published 08/31/2021

Medical review is the collection of information and clinical review of medical records by Palmetto GBA to ensure that payment is made only for services that meet all Medicare coverage, coding and medical necessity requirements. Medical review activities are directed toward areas where data analyses indicate questionable billing patterns.

The goal of the medical review program is to reduce payment errors by identifying and addressing billing errors made by providers concerning coverage and coding. To achieve the goal of the medical review program, Palmetto GBA:

  • Proactively identifies patterns of potential billing errors concerning Medicare coverage and coding made by providers through data analysis and evaluation of other information (e.g., complaints)
  • Reviews data analysis reports
  • Takes action to prevent and/or address the identified error

Additional Resources

Ambulance Services ChecklistPortable X-Ray ChecklistChest X-Ray ChecklistBone Density Study ChecklistTargeted Probe and Educate VideoTargeted Probe & Educate (TPE) Provider ContactPalmetto GBA Partnering with Providers to Get it Right the First TimeMedical Review Intent to Reopen Process for Non-Receipt of Medical Record DenialsOverview of Prepayment and Postpayment Claim ReviewAdditional Documentation Request (ADR) Separator SheetAlways Supply Medical Records When Requested by the Benefit Integrity UnitRailroad Medicare Implemented Automated Calls to Assist Providers with ADR ResponsesChiropractic Claims Submitted with Both the 'AT' and 'GA' Modifier to RejectRailroad Medicare and the Targeted Probe and Educate ProcessTargeted Probe and Educate: September 2021 to September 2022 Planned ReviewsDenosumab ChecklistAmbulance Reason Code CrosswalkMedical Review Prepayment Reviews: October 2021-September 2022 Planned ReviewsActive Medical Reviews: October 2021 Through September 2022Active Medical Reviews: October 2021 Through September 2022Targeted Probe and Educate Process ModuleEntries in Medical Records: Amendments, Corrections and AddendaMedicare Medical Records: Signature Requirements, Acceptable and Unacceptable PracticesMedical Review Postpayment Reviews: October 2021 Through September 2022 Planned ReviewsMedical Review TPE Reviews: October 2021 - September 2022 Planned ReviewsAflibercept ChecklistRanibizumab ChecklistSpecial Stains: Group 1 for Microorganisms ChecklistSurgical Pathology: Gross and Microscopic Examination of a Specimen ChecklistControlled Substance Monitoring and Drugs of Abuse Testing ChecklistTherapeutic Procedures ChecklistNational Expansion of the Repetitive, Scheduled Non-Emergent Ambulance Transport (RSNAT) Prior Authorization Model (MLN Fact Sheet)Review of Diagnostic Radiology: Bone Mass Measurement ServicesMedical Review of Ambulance Emergency TransportsMedical Review of Ambulance: Non-Emergency TransportsReview of Diagnostic Radiology: Chest X-Ray ServicesReceiving and Responding to a Palmetto GBA Additional Documentation Request for Postpayment ReviewCMS Repetitive, Scheduled Non-Emergent Ambulance Transport Prior Authorization Model Operational GuideCMS Letter to Railroad Medicare Ambulance SuppliersWe're All in This Together!Medical Review: Additional Documentation Requests (ADRs)Medical Review Program and Targeted Probe and Educate HandoutImplementation of Prior Authorization for Repetitive, Scheduled, Non-emergent Ambulance Transports Webinar: July 12, 2022